The “blame-game” and demands for action against doctors will not help and needs to be stopped. It is better to think of the changes in the system to reduce medical malpractice

Yesterday we carried the first part of the series titled “Healthcare system controlled by pharma companies at the cost of patients”. Today we have the second part which deals about the ways to curb medical malpractice and ensure healthcare to all.

Once we know what is wrong with the present system, it should not be difficult to plan out a strategy to improve the system. But first, it is absolutely essential to stop the blame-game. Threats of punitive action against the doctors only vitiate the atmosphere, puts them on the defensive and will only worsen the situation and escalate costs. Immensely better results will be obtained by changing the system, so that the ‘Good’ is encouraged, and the ‘Bad’ is curbed. Only then can the small percentage of persistent defaulters be punished.

The main fault in the present system is obvious—private healthcare has an uncontrolled monopoly because the public healthcare system is grossly inadequate. State governments are most reluctant to increase their responsibilities and restrict themselves to “free treatment” for the poor. But nothing is free—so the tax payers pay. Thus, there is no correlation between the contributions towards healthcare services, by a patient or the community, and the expenses incurred thereon. This makes the whole system irresponsible and hence unresponsive. The worst culprit is the government bureaucracy who pays nothing and yet gets (really) free treatment—even in private hospitals. From the peon to the minister, they do not contribute a single paisa for their healthcare. And they form a formidable 12% to 15% of those who can afford to pay. Therefore, the concept of ‘free’ treatment must be opposed, and at the same time, public healthcare services must be widely expanded and made at least partially competitive to the private sector.

 A report of the High Level Expert Committee on Universal Health Coverage for India (commissioned by the Planning Commission), released on 26 November 2011, recommends that government spending on health must increase from 1.2% to 2.5% by 2017, and to 3% by 2022. The committee also advises that at least 70% of the budget must be for primary health. If this is done, there will be a substantial increase in primary healthcare centres and substantial improvement in district/taluka hospitals which offer secondary care.

I do hope that not more than 10% out of this budget is used for expanding tertiary healthcare. High-tech modern equipment and the highly-trained staff eat away the bulk of the tax payers’ money. More than 40% of the health budget of the Mumbai municipal corporation is used up by tertiary healthcare, while there are almost no patients in the 170 primary healthcare centres in the city for want of good doctors and simple diagnostic facilities. The health indices of Asian countries conclusively prove that primary and secondary healthcare improves overall health and increases the life-span of a community substantially, whereas the tertiary care has almost no impact on the society as a whole. The reason is simple—only a few need tertiary care. If it is presumed that one in 500 need tertiary care and it is accepted that such a person gets 10 additional years to live, the community, as a whole, benefits  by just seven days—ceterus parebus—individuals benefit but not the society. The inference is simple—tertiary services must be developed and run with a separate budget, even in the public sector, and it must be supported by specific separate tax on the affordable classes. The budget on healthcare must be spared of these frivolous expenses.

Organisation of health services is equally important. The government is justified in offering healthcare in public hospitals at nominal charges, or free to the poor. But many opportunists take advantage of this while the poor are sidelined and remain neglected. Can we identify the poor, not-so-poor, and those who can afford to pay amongst those who attend public hospitals? If so, the poor can be treated free, the not-so-poor at partially subsidised rates (about 25% of cost) and those who can afford must pay full cost. This will allow public hospitals to earn some legitimate revenue to be used for maintenance, repairs and expansion (some autonomy must also be given to the hospital-in-charge.)

Most countries require patients to attend a primary doctor first, and are referred to a secondary hospital only if required. If we follow the same system, only those among the poor, who have attended the primary doctor first and are referred for further treatment, can be considered for treatment at nominal charges. They will also have separate timings at a public hospital. Those who approach secondary centres directly or are referred through the private sector will be considered not-so-poor. They will have separate timings and be charged at least 25% of the cost of treatment.

The IRDA (Insurance Regulatory & Development Authority) chairman describes them as “preferring to hop in an auto and go to the hospital, instead of going to the primary health centre”. The class who can afford to pay can also be induced to seek treatment at public hospitals, if pay clinics are allowed in the evening hours for senior specialists, and maybe 20% beds are separately reserved for them. This class will pay full costs and specialists will be entitled to collect “doctor’s charges” from them. This incentive will help the government to retain good specialists and also prevent these patients from taking advantage of “Free Treatment” in the morning hours. Public sector hospitals will become competitive and will help curb private sector hospitals’ exploitative tendencies to some extent. Public hospitals will display their charges and this will foster transparency in the entire sector. In this system, even tertiary treatment can be offered to the poor and the not-so-poor classes, if they are properly referred under strictly defined parameters.

Doctors need to be disciplined too. In order to curb the misuse of high-tech healthcare, it is absolutely essential that primary healthcare providers (both in public and private sector) are prohibited from ordering high-cost therapy and medicines like the latest antibiotics. A schedule of therapy and drugs can be easily prepared (say-schedule-sp). If these doctors feel that the patient really needs such advice, he must refer that patient to a specialist or a hospital. Similarly, there ought to be a rule for all new imported drugs introduced in the country. This single administrative step might control the abuse of modern technology by 50%. It will not harm any patient, as the doctor is obliged to refer the case to a specialist or a hospital. In fact, it may effectively reduce the “cut-practice” to an extent.

Fresh medical graduates will need to be re-oriented to become primary health providers, as most of them are not trained for it at all. They are taught to investigate, and treat patients with the most modern methods, and hence have neither the knowledge nor the expertise to treat the patients with simpler methods. They ought to be posted for a year or two in district hospitals, while simultaneously attending primary healthcare centres. Lessons in socio-economic realities of communities would help a lot. Competence automatically reduces malpractice. Even if these doctors decide to leave the public sector and become private general practitioners, it would be a blessing in disguise.

Insurance companies are not helping either. They cry about losses, but continue to increase premiums and support 5-star tertiary hospitals, at the cost of the average insurer. How does one explain why a bill of Rs35,000 is approved only after several objections, while a bill of Rs1lakh for the exact same treatment from a 5-star hospital is cleared without a question? A bill of Rs60,000 for hysterectomy from a nursing home was rejected; when the same patient had been given an estimate of Rs1,50,000 by a 5-star hospital which was pre-approved. Clearly, this attitude benefits tertiary hospitals and patients want to be treated at the “best” hospital even if their coverage is marginally above the estimated bill. An insurance company pays and later increases the annual premium of the policy—no extra medical benefit at all.

The central government is supposedly planning “universal health coverage”. The IRDA chairman estimates that a premium of only Rs400 per annum for this scheme would be required, but doubts whether such a low premium will suffice, as people are paying more than Rs15,000 for their mediclaim policies today. I am equally sceptical, unless the coverage restricts itself to cover primary and secondary health-care services. A defined standard of service would be provided under the scheme, and the medical centre will receive charges at a previously defined rates. For better facilities, individuals can top-up their own policy (by paying) for additional expenses. The advantage of the scheme is that people can utilise the services from recognised private health-care centres (if the government approves it). Thus, private and public health services will become competitive and bring down costs in the private sector to an extent.  The concept of “free treatment” would be replaced by collective payment, through insurance. It is stipulated that the salaried and higher income groups will pay a proportionate premium while the government will pay the premium for those below the poverty line. The scheme looks attractive. The dangerous dragons are bureaucrats who may swallow a major chunk of the budget. These 15 crore ‘affluent’ do not have the slightest inclination to pay for any services they get. Compulsory monthly deduction at source from them must be demanded by vigilant activists to save the scheme from failure.

But the biggest lacuna in government schemes is the neglect of professionals—the doctors. It is repeatedly stated that doctors are not willing to work in rural areas. This is absolutely false. Vacancies are due to the administrative difficulties in filling the posts and not due to lack of applicants. A large percentage of doctors are working on ‘temporary’ basis and are re-appointed every year after one day break in service. They are not entitled to leave, increment or perquisites; some have been working like this for more than 10 years. Their salaries are inadequate, but my own experience tells me that better salaries do not guarantee better performance. A fixed salary ensures minimal performance; therefore, all professionals must be given performance-based incentive payment. Fees must be defined for every service, collected and paid to the doctors, from primary healthcare centres to the tertiary hospitals. It will ensure that government doctors earn the same as his counterpart in private practice. Universal health coverage may fail like other government schemes if “performance-based payment” principle is ignored. I have been advocating this for a long time.

Another way to curb the abuse of technology is the use the internet effectively. A little research on treatment prescribed by a doctor would help most patients. This will create consumer awareness and allow patients to question doctors. After all “knowledge is power” and doctors too will become more cautious. I foresee a tremendous scope for retired professionals, consumer activists and qualified social workers to start a “Medical Information Centre” in front of every big hospital or polyclinic to help guide patients.

A summary of what needs to be done:
a)    The “blame-game” and demands for action against doctors will not help and needs to be stopped. It is better to think of the changes in the system to reduce malpractice.
b)    Public sector and primary healthcare must expand. Public sector should cater to everyone, especially the poor, and become competitive to the private sector.
c)    Doctors must be prohibited from prescribing costly drugs and expensive therapies and investigations. This domain should be restricted to specialists.
d)    The behaviour of the specialists and hospitals should be regulated with a specific code of conduct. But their clinical decisions are “Expert Opinion” and should not be challengeable. Consumer Protection Act should not be made applicable to the medical profession.
e)    Tertiary healthcare needs to be re-looked. At least, it should not be allowed to eat away the budget for primary and secondary care in public sector. It needs to be funded strictly by those who need it.
f)    Doctors need to be re-oriented for primary healthcare. The present education system is faulty and promotes specialisation and super-specialisation which is against the interests of the society.

If these changes are made, defaulters would be few and then, it would be easy to take punitive action against them.

(Dr Sadanand Nadkarni, 80, is the former Dean of Sion Hospital, author of several books, a serious thinker of medical issues and hugely respected for a series of path-breaking ideas on improving the delivery of medical services to the aam aadmi. His book “Management of the Sick Healthcare System” is among the first to speak out about medical malpractice and other issues).